Authored By:Nayara Abreu
Royal Holloway, University of London
“They were already given me the impression that they had given up on me.” These words, spoken by 22-year-old Nothando Nhilziyo after months of dismissed symptoms prior to her eventual terminal cancer diagnosis, encapsulates a painful and widespread experience among Black women in the UK. Her case is not merely a personal tragedy but a window into a systematic problem: the consistent dismissal, disbelief and inadequate treatment of Black women within the National Health Service. Such patterns raise profound questions not only about clinical failings, but about the extent to which this treatment conflicts with the legal rights owed to every patient under the Equality Act 2010.
Across the UK, research, inquiries and patient testimonies converge on a clear conclusion: Black women’s pain is often not taken seriously, their symptoms are more likely to be minimised, and they face structural barriers to receiving timely, appropriate care. A stereotypical narrative of the ‘strong black woman’ frequently describes a cultural tendency among practitioners to downplay their suffering. The consequences are not abstract. Delayed diagnosis, avoidable complications, and disproportionately poor maternal outcomes persist across NHS services, despite repeated calls for reform.
This article examines these disparities as a legal issue. The Equality Act 2010 imposes specific obligations on healthcare providers, prohibiting discrimination and requiring organisations to take proactive steps to achieve equality. Yet the evidence suggests that many of these obligations are not being met. Through an analysis of personal testimonies, clinical evidence, legal duties and structural shortcomings, this article argues that the treatment of Black women within the NHS may constitute not merely a moral failure, but a breach of statutory equality rights.
The Recurring Theme of Dismissed Pain
The story of Nhilziyo is striking not because it is unique, but because it closely resembles numerous other accounts. Black women consistently report that their symptoms are met with scepticism or minimisation, even when they clearly describe severe or worsening conditions. This trend is particularly visible in areas such as general practice consultations, emergency care, oncology, and maternity services. Tragically, a Liverpoolian Black mother-to-be contributed to these growing statistics – where her acute pains led to the fatality of her unborn child and unfortunately, met her fatal destiny 48 hours after.
The Black Equity Organisation curated a report, which captures Black women’s experience in their own words, highlighting a shared perception: the clinicians often assume Black women possess an unusual resilience to pain. This stereotype, rooted in centuries-old racial biases tracing back to colonial medicine and pseudoscientific beliefs about biological difference, continues to shape modern clinical judgements. Although contemporary healthcare professionals would not consciously endorse such assumptions, implicit biases – unconscious associations formed through societal conditioning – continue to influence decision-making.
In practical terms, this results in Black women being less likely to receive appropriate pain relief, less likely to be referred for diagnostic testing at early stages, and more likely to be sent home without adequate investigation. Where a white patient describing similar symptoms might receive immediate imaging or blood tests, Black women report being told their symptoms are ‘normal,’ ‘stress-related’ or ‘nothing to worry about.’
Clinical Evidence of Inequalities
The disparities experienced by black women are not only reflected in personal testimonies but are consistently documented in clinical data. Nowhere is this more alarming in maternal health. Reports from MBRRACE-UK have repeatedly found that Black women are significantly more likely to die during pregnancy and childbirth compared with white women. The gaps remain ever after controlling for socio-economic status, age, health behaviours and existing medical conditions. These findings challenge any attempt to rationalise the disparities as products of external factors. Instead, they suggest systematic failures in responsiveness, diagnostic decision-making, and escalation of care.
Further evidence highlights additional patterns. Black women are more likely to experience delayed diagnosis for cancers, including breast and cervical cancer. They are more likely to have their early symptoms dismissed or attributed to lifestyle causes rather than investigated through imaging or specialist referrals. The cumulative effect is later-stage detection, which is associated with poorer survival rates.
To understand these disparities, scholars point to three interconnected factors: diagnostic bias, structural exclusion, and inadequately representative clinical research. Diagnostic bias arises when clinical judgements are unconsciously influenced by a patient’s race. Structural exclusion refers to institutional frameworks that unintentionally disadvantage minorities, for example, rigid triage pathways that rely on patient self-advocacy, or limited appointment times that penalise patients who require more detailed communication. Underrepresentation in research compounds these problems, as treatment guidelines and diagnostic criteria often reflect data derived primarily from white populations, making them less responsive to the needs of Black women.
These factors do not exist in isolation; they intersect and reinforce one another. The consequence is a system in which Black women are systematically less likely to receive equitable care.
Obligations under the Equality Act 2010
The Equality Act 2010 establishes clear standards for how healthcare providers must treat patients. It prohibits discrimination on the basis of protected characteristics, including race, sex, and pregnancy and maternity. It also creates positive duties requiring public bodies to actively address inequality.
The treatment experienced by Black women raises questions under several provisions of the Act.
Section 13: Direct Discrimination
Direct discrimination occurs when a person is treated less favourably because of a protected characteristic. If clinicians dismiss Black women’s pain or symptoms due to racialised assumptions about pain tolerance or exaggeration, that treatment may amount to direct racial discrimination. Although discriminatory intent is not required for a violation, the outcome must show clearly less favourable treatment compared to similar patients of another race. The consistent pattern of pain minimisation suggests this threshold may be met.
Section 19: Indirect Discrimination
Indirect discrimination arises where a seemingly neutral policy or practice disproportionately disadvantages a protected group. In healthcare, this is particularly relevant to standardised diagnostic pathways, triage systems, or appointment structures that fail to accommodate differences in symptom presentation among Black women. For example, a protocol that denies imaging unless certain stereotypically ‘textbook’ symptoms are present may indirectly disadvantage black women if their symptoms commonly present differently. Unless justified as proportionate and necessary, a high threshold, such practices may breach section 19.
Section 17: Pregnancy and Maternity Discrimination
Given the concerning disparities in maternal mortality and morbidity, potential breaches of section 17 warrant serious scrutiny. Reports indicate that Black women are less likely to be listened to during childbirth, less likely to have concerns escalated, and more likely to have warning signs overlooked. If these patterns reflect structural biases, they may constitute unlawful discrimination during pregnancy and maternity.
Section 149: Public Sector Equality Duty
Perhaps most critically, section 149 imposes a proactive obligation on public bodies, including NHS organisations, to have due regard to the need to eliminate discrimination and advance equality. This duty requires more than passive compliance; it demands active measures to identify and address disparities. Yet repeated reports, from: MBRRACE-UK, Kings Fund and independent inquiries, have highlighted persistent racial inequalities in healthcare outcomes. The recurrence of these findings suggests that NHS bodies may not be meeting their statutory responsibilities to address the known and foreseeable risks faced by black women.
Legal scholars have increasingly questioned whether the continued presence of such disparities should be interpreted as systematic non-compliance with PSED. At minimum, the evidence points to significant shortcomings in monitoring, accountability and enforcement.
Beyond Clinical and Legal Duties
Even where legal obligations are ambiguous or contested, the ethical imperatives are clear. Healthcare is grounded in four core principles: autonomy, beneficence, non-maleficence and justice. Each is compromised by the disparities faced by black women.
Autonomy is undermined when symptoms are dismissed, preventing informed decision-making. A patient cannot meaningfully participate in their own care if their concerns are not believed. Beneficence, the obligation to act in their patient’s best interest is violated when clinicians fail to fully investigate symptoms reported by black women, or when decision-making is clouded by unconscious bias. Non-maleficence, the duty to do no harm, is clearly breached when delayed diagnoses cause avoidable suffering or fatal outcomes. Justice, perhaps the most important principle in this context, demands fairness in healthcare delivery. Persistent racial disparities represent a profound departure from this commitment.
From an ethical standpoint, the NHS cannot aspire to equity without directly addressing the role of bias, cultural misunderstanding, and structural inequality in shaping patient outcomes.
What must change-
For the NHS to comply with its legal and ethical duties, reform must be structural rather than superficial. Training programmes on unconscious bias, although valuable, cannot be effective unless paired with systematic changes to diagnostic process, data collection and accountability mechanisms.
Firstly, clinical guidelines must reflect the experiences of a diverse population. This requires a thorough review of common diagnostic tools and pathways, many of which were developed or non-representative datasets. Conditions such as cancer, cardiovascular disease and pre-eclampsia may present differently across races; guidelines must account for this nuance.
Secondly, data collection must be strengthened. The NHS cannot meaningfully address inequalities without accurate, disaggregated data. Current reporting often lacks detail about ethnicity, gender and socio-economic background, limiting the ability to identify patterns. Transparent publication of such data is essential.
Thirdly, patient advocacy services should be expanded and made more accessible to black women who may fear being dismissed or who lack the confidence to challenge clinical decisions. Research shows that advocacy significantly improves outcomes in populations vulnerable to discrimination.
Finally, meaningful enforcement of the public Sector Equality Duty must be prioritised. Equality impact assessments should not be viewed as bureaucratic exercises but as legal requirements with genuine consequences. Failure to address persistent disparities should trigger regulatory intervention.
The disparities in healthcare treatment experienced by Black women in the UK are persistent, well-documented, and deeply troubling. The case of Nothando Nhliziyo reflects a broader pattern — one in which Black women’s symptoms are dismissed, their pain minimised, and their concerns overlooked. When examined through the lens of the Equality Act 2010. These disparities reveal potential breaches of direct discrimination, indirect discrimination, pregnancy and maternity protections, and — perhaps most significantly — the Public Sector Equality Duty.
These legal concerns sit alongside serious ethical implications. A healthcare system that treats pain, risk and urgency differently based on race cannot claim to uphold the fundamental principles of medical ethics. The NHS cannot fulfil its mandate to provide fair, safe and effective care while such disparities persist.
Meaningful reform requires more than awareness; it demands structural change, legal compliance and genuine accountability. Equity in healthcare is not aspirational. It is a legal duty and a moral necessity.
Bibliography
Table of Statutes
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